FAMILY COUNSELING FORM
Describe relationship between your child and the following people:
Treatment (Current and Previous)
Pregnancy History/ Mother
During pregnancy, did the mother:
During the pregnancy were there any complications?
As well as you can remember, where there any delays in the follow areas?
History Substance Use
(please indicate if currently using)
History of Abuse
History of Trauma
Suicidal / Self Harm
Print hard copy to fill out and hand in.